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FOR OFFICE USE, <br /> APPLICATION FOR SANITATION PERMIT <br /> (Complete in Triplicate) Permit No. ............... ..... <br />•-•--•-•••�-••........-•.......... ........... This Permit Expires 1 Year From Date Issued <br /> Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein <br /> described. This application is made in` compliance with County Ordinance No. 549 and existing Rules and Regulations: <br /> JOB ADDRESS/LOCATIO �_ -3 . l.i�/3-.. <br /> -- -�--�.•.M.... . .. ... ........ .................CENSUS 'TRACT --•-•--... ............... <br /> Owner's Name ... ........... .. ... .............:...Phone _.._... ............................ <br /> Address - d <br /> ..f ..- - ..._. .. <br /> �...... .. .. _...-.... __ City -- •-�--•.... ....... ..............................•--._..... <br /> Contractor's Name .. ,,, -. .. ct.�- i.-�_ .--.License # .1 SX 3.c��-- Phone .............................. <br /> Installation will serve: Residence ❑ Apartment House[_] Commercial ❑Trailer Court <br /> r� Motel ❑ Other ...... .....— --------•....----._.;.:_._ <br /> Number of living units: /..... . Number of bedrooms ............Garbage Grinder . .......... Lot Size .._..���+r{- `-�3 __..--.. <br /> Water Supply: Public System and name . ... ........... ..................- ..__..... ............. --- Private <br /> Character of soil to a depth of 3 feet: Sand Silt❑ Clay ❑ Peat 0 Sandy Loam Clay loam ❑ <br /> Hardpan ❑ Adobe ❑ Fill Material ....... .... If-yes, type ...... ... .... ....... . <br /> (Plot plan, showing size of lot, location of system in relation 'to wells, buildings, etc. must be placed on reverse side.) <br /> NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,l <br /> PACKAGE TREATMENT [ } SEPTIC TANK ] Size--------------------------- ...... . Liquid Depth ......................... <br /> Capacity Type ---------------- Material.._:.... .... No. Compartments ....................� <br /> Distance to nearest: Well ' --------------Foundation- ..... Prop. Line ....................� <br /> LEACHING LINE [ ] No. of Lines _ Length of each lineTotal Length ..... ....................p0 <br /> 'D' Boz Type Filter Material ....................Depth Filter Material ..._.._.-._..„_.- .............---.-_._.. <br /> Distance to nearest: Well --------- ----•- - --._ Foundation .. Property Line .............._......_Z <br /> SEEPAGE PIT [ ] Depth _ Diameter ---_---------___ Number ...... ........... Rock Filled Yes ❑ No Q. <br /> Water Table Depth ....... .r................--.......Rock Size - ------ <br /> Distance to nearest: Well _.. ........... ..................Foundation', --.- ....... Prop. Line ...................� <br /> REPAIR/ADDITION(Prev. Sanitation Permit# ._._._.. . ........ . ............. Date _... .__.....-._.-•---------....) <br /> Septic Tank (Specify Requirements) .................. . .................:............ .....-.............................. <br /> ... <br /> Disposal Field (Specify Requirements) <br /> .. . ......... <br /> ----._.._...... ............................ ...--------- 1............................................. ....... ................................................................. <br /> ......... . ............... ............-----... ..---------.......... . _....----._..... -- -----.....--- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin local Health District. Home owner or licen- <br /> sed agents signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to orkman's Compensation laws of California.” <br /> Signed . . ........C. Owner <br /> BY . ...... .-. _ . ... .. Title '-tom .._ . . .. <br /> (If other than owner[ <br /> R DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY . �.r DATE `j 1(�'..... ..................... <br /> BUILDING PERMIT ISSUED - ----- .-. .............. ...... ... .... .... .. . . .. ..........DATE _ ...... ••-- <br /> ADDITIONAL COMMENTS .... ....... . ....... .. <br /> -----------------— ---------...-------•-•- ..-- -•---- <br /> --- ---- . <br /> Final Inspection 6 <br /> P Y: -� -- •-- -- -.._--- - . _...-�-----•--•--------- •---•-•------•--------•..:.............• �-- •-•---------.....Date 1�.--�� . ......---......._.------- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 0 <br /> E. H.13 24 1-'68 Rev. 5M 7/72 3 M ' <br />